Provider Demographics
NPI:1245123835
Name:DERMATOLOGY SKIN STUDIO PC
Entity type:Organization
Organization Name:DERMATOLOGY SKIN STUDIO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:STALL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:319-400-3085
Mailing Address - Street 1:3205 ZENITH AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1084
Mailing Address - Country:US
Mailing Address - Phone:319-400-3085
Mailing Address - Fax:
Practice Address - Street 1:3205 ZENITH AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1084
Practice Address - Country:US
Practice Address - Phone:319-400-3085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-02
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily